Daniel Forman, MD, is Medical Director of the Cardiac Rehabilitation and Exercise Testing Laboratory at Brigham and Women's Hospital. Dr. Forman suggests that while most of focus of heart care is placed on diseases of the heart, there is an enormous opportunity to modify biology and lifestyle years before cardiopulmonary disease ever shows up. Lifestyle factors such as eating habits, exercise habits, tobacco use and sleep add up over time and lead to disease. Add biological factors like age, family history, and genetic predispositions and there are many factors that lead to disease.

Dr. Forman shared two studies that showed the impact of using stents on patients pales in comparison to the impact of heart patients who exercise in preventing recurrence of heart attack in patients with cardiovascular disease. However, as the patient ages exercise becomes a less likely treatment. Dr. Forman reports that the lifestyle risk factors (tobacco, sedentary, obesity) all speed up the biological process of aging making the body less able to handle exercise as biological aging continues and the vessels of the heart begin to stiffen.

While functional capacity is diminished as a person ages, Dr. Forman shows proof that aerobic training benefits even the older patient. Exercise can turn around the biology of arterial stiffness when it is included in the regimen of care. Dr. Forman goes on to say that attacking cardiovascular disease and the risk factors that lead to disease becomes more important as the patient ages. He suggests clinicians need to get aggressive beyond the prescription of medicine.

"Walking is as important as this statin, it is a life or death decision" should become a part of the language of treating risk factors. The U.S. Department of Health and Human Services has created physical activity guidelines for Americans that Forman believes should be a part of our regular conversation and prescription for our patients. Additionally Dr. Forman suggests that cardiologists measure functional capacity and use that as an indicator of mortality from cardiovascular illness.

In the hospital environment Dr. Forman cautions that bed rest is one of the worst things we can do for patients. As a person rests, their capacity for physical function decreases, which increases the amount of effort required to do even minimal tasks. This stress on the body comes at the worst time, as recovery happens much faster when the body is under less stress. Forman believes that even small amounts of physical activity with the patient in the hospital maintains the patient's ability to function physically vastly improving their outcome.

Dr. Forman urges clinicians to look beyond disease and help the patient understand the importance of activity and lifestyle as the single most important factor that a patient can affect. Physical activity attacks the root of the cardiovascular disease as well as the symptoms. Physicians should help the patient understand the barriers that keep them from exercising and help the patient problem solve those barriers so that they can get on with the most important part of prevention of disease. The single largest barrier is that the primary care physician has not often prescribed exercise, so discussion with the patient about how to make lifestyle changes that include a plan to increase physical activity is essential.

The question Forman continues to ask, "Who should pay for the cost, space, specialty, and supervision of the exercise program?" Today there is not one part of the health care system that has stepped up to responsibility for the delivery and management of physical activity programs. Forman also argues that we need to agree on a single way to assess physical function and begin measuring patients based on this assessment. Dr. Forman concludes that physical activity as a therapeutic recommendation is the future of health care that we need to begin practicing today.

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